Integrative medicine — which calls for a patient-centered, culturally sensitive, whole-person, multidisciplinary approach to care — has the potential to become a cornerstone in the national effort to increase access to quality health care at a reasonable cost. This emerging health care specialty just got a boost. Effective in 2014, Section 2706 of the Affordable Care Act, titled "Nondiscrimination in Health Care," states that insurers may not discriminate on plan coverage against any health care provider that is acting within the scope of applicable licensure under states’ laws.
The state of Hawaii maintains boards for acupuncture, chiropractic, naturopathy and massage therapy. While these professions were already accessible through Hawaii State Workers’ Compensation, Auto Personal Injury Protection and to a limited degree among private insurers, Section 2706 has required all private carriers to review policies for participation and reimbursement. Section 2706 does not require payers to accept any and all types of providers into their networks, nor does it dictate changes in benefit packages or covered services. Also, carriers retain discretion on reimbursement rates, which may be subject to quality performance and market factors.
However, beginning this year, newly recognized professionals can now submit claims so long as they are covered by a given plan, within their licensed scopes of practice as defined by the state, and the care is medically necessary. Section 2706 does not require insurance companies to bring on every provider type as "participating." The difference is that for "nonparticipating" professions or providers, patients typically pay at the time of the service. Once the carrier receives a proper claim, reimbursement is sent directly to the patient. Depending on the carrier and the policy, reimbursement to patients for nonparticipating providers ranges from 50 percent to 80 percent of the total charge.
The ball is in motion, but, like the rest of Obamacare, it will take time for patients, carriers and providers, both complementary and conventional, to get it right so everyone wins. As the door swings open, carriers need to understand how to manage these benefits effectively. They also need to learn what value their clients, mostly large employer groups, place on such services. Many new providers will need to learn a different skill set that includes billing, standards of care, medical documentation and how to interface with the existing medical community. Conventional physicians have questions and concerns regarding the safety of their patients, especially in the case of concurrent care.
The patient-centered medical home, a place where people can come for the full range of their health care needs, is already central to health care reform.
It is also the marrow of the integrative medicine strategy. Most important, integrative medicine emphasizes robust collaboration among the members of the care team together with patient choice and responsibility. In addition to caring for serious health problems as they arise, integrative medicine employs wellness and lifestyle medicine for prevention and treatment. Section 2706 begins to clear the way for professionals, important to the team, to participate in the patient-centered medical home in an economically viable way.
Special programs designed to manage some of the most challenging and expensive health issues may be the most effective way to harness synergies enhanced by the broader treatment team. Diabetes, obesity, sleep apnea, chronic pain, attention deficit hyperactivity disorder, and heart and lung disease are all conducive to multidisciplinary, team-based care.
Section 2706 has started a sea change in the relationship of complementary and alternative professions to conventional medicine, but the work is just beginning. An acculturation process is essential for all parties — patients, providers and carriers.
Integrative medicine and the patient-centered medical home represents a low-risk, high-yield opportunity to play to the strengths of the full range of well-trained, licensed providers. Carefully designed special programs for select health issues offer an outstanding way to optimize outcomes and deliver access to quality care at reasonable cost.
Ira “Kawika” Zunin, M.D., M.P.H., M.B.A., is a practicing physician. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
